helen keller award application - lions eye...
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Recipient's Name _________________________________________________________
Recipient's Address _______________________________________________________
Recipient's Email address _________________________________________________
Recipient's Home Club ___________________________________ District _________
Proceeds will be used for capital campaign and major equipment purchases
Each Helen Keller will receive a lapel pin, destinctive plaque and club banner plate
PLEASE ALLOW 3-4 WEEKS FOR PROCESSING.To request expedited arrangements, please email your request to [email protected]
Send your $1,000 check payable to the "Lions Eye Foundation" to:
Lions Eye Foundation c/o Lion John Schroeder P.O.Box 2302 Santa Cruz, CA 95062 Not actual size
HELEN KELLERAWARD APPLICATION
This award is needed by ____________ Memorial award? [ ] yes [ ] no Honorary award? [ ] yes [ ] noHas the recipient received a Helen Keller Award before this? [ ] yes [ ] no
(Please check one)[ ] Please mail award to above address [ ] Instead please mail award to: ______________________________
Contact phone # ____________If the amount enclosed is less that the full $1,000 contribution, I hereby commit to making payments of at least $200 per year. __________________________________ (signature)